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Orthopaedics and Rheumatology > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

How is non-inflammatory, inflammatory, septic and haemorrhagic arthritis quickly distinguished on joint aspirate?

A

> 50’000 WCC’s or >75% neutrophils is highly suggestive of septic arthritis even if gram stain -ve

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2
Q

What is the conversion between WBC/mm3 to WBC/uL for joint aspirate analysis?

A

The same
2000/mm3 = 2000/uL

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3
Q

What is the sensitivity of a Gram stain of synovial fluid for bacteria?

A

29-50%
Thus a postive gram stain rules septic arthritis in but a negative one cannot rule it out

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4
Q

Which micro-organisms are unlikely to be seen on synovial fluid gram stain?

A

Mycoplasma
Mycobacteria
Fungi

Also early in the infection normal organisms may not be seen

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5
Q

When should septic arthritis still be suspected even if the gram stain is negative and crystals are present?

A

If the PMN ratio is >75%
If the WCC/mm3 or uL is >20,000
If the patient is clinically presenting as septic

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6
Q

What are the risk factors for septic arthritis?

A

Penetrating trauma/recent surgery to the joint
Poorly controlled diabetes
IVDU
Immunosuppression
Pre-existing arthritis in the joint (including gout)
Overlying soft tissue infection
Advanced age
Indwelling catheters

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7
Q

What are the most common organisms causing septic arthritis?

A

Staph aureus (most common)
Strep pneumoniae
Pseudomonas aeruginosa (immunosuppressed and IVDU)
Polymicrobial (trauma)
N. gonorrhoea (Active STI)
Mycobacteria/Fungi (immunosuppressed, indolent course)
Viral (Rubella, Dengue, Ross River, usually polyarthritis)

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8
Q

What is the Gustilo-Anderson classification for open fractures?

A
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9
Q

What is the Weber classification for ankle fractures?

A
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10
Q

In open wounds exposed to sea water, what organisms should be covered and with what agent?

A

Vibrio species

Doxycycline or Azithromycin or Ciprofloxacin

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11
Q

What is the basic management of an open fracture?

A

Clean the site (water +/- antiseptic)
Analgesia
Prophylactic ABx (Cefazolin etc)
Sedate then reduction
Plaster immobilisation
Keep elevated
Refer to orthopaedics for ORIF

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12
Q

What should always be assessed with fractures and dislocations?

A

Distal arterial pulses
capillary refill
Sensation and nerve function
Signs of compartment syndrome

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13
Q

How are upper limb nerve injuries quickly assessed for if injury below the elbow?

A

Radial- wrist drop, snuff box paraesthesia

Median- Lateral hand sensation, thumb abduction, ok sign

Ulnar- Medal hand sensation, finger abduction

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14
Q

What other structures are commonly injured with a tibial plateau fracture?

A

Medial collateral ligament
Meniscus on same side

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15
Q

What are the risk factors for achilles tendon rupture?

A

Male sex (5:1)
Older age
Sport (recreational 80% cases)
Flouroquinolone use
Glucocorticoids
Obesity
Pre-existing achilles tendinopathy

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16
Q

What is Thompsons test for achilles tendon rupture?

A

With the patient lying prone with feet over the end of the bed, squeeze the gastrocnemius and the foot should plantar flex
If does not plantar flex then suggestive of complete tendon rupture

17
Q

What is the management of an achilles tendon rupture?

A

Complete- RICE, analgesia, place in below knee back slab with partial plantar flexion (equinus cast), refer to orthopaedics (surgical vs conservative Mx)

Partial- RICE, analgesia, CAM boot, outpatient ortho follow up

18
Q

What are the risk factors for ACL tear?

A

Female
Younger age
High level sport
Sport whilst fatigued
Trauma/contact sport

19
Q

What are the best physical exam tests for ACL injury?

A

Lachmans test- Knee 30 degrees flexion, pull tibia anteriorly, increased translation compared to normal side

Anterior draw test- Knee 90 degrees flexion, pull tibia anteriorly while sitting on the foot, increased translation compared to normal side

20
Q

How is ACL tear diagnosed and what is the treatment?

A

MRI is the gold standard

RICE, analgesia, crutches and non-weight bearing
Refer to orthopaedics for consideration of surgery vs conservative management

21
Q

What are the potential complications of a knee (tibiofemoral) dislocation?

A

Peroneal nerve injury
Popliteal artery injury
- thrombosis, tear, pseudoaneurysm
Meniscal injuries
Cruicate ligaments (posterior 1)
Collateral ligaments
Compartment syndrome
DVT
Joint instability
OA
Chronic pain

22
Q

How is a tibiofemoral knee dislocation relocated?

A
23
Q

What is the “pucker/Dimple/buttonhole” sign with tibiofemoral dislocation and what is its significance?

A

Pathognomonic of posterolateral tibiofemoral dislocation
A dimple or invagination of the tissue at the distal anteromedial thigh

Posterolateral TF dislocations are irreducible with closed reduction, and attempts to reduce in this fashion increase the risk of skin necrosis

24
Q

What is the typical test used to test median nerve function with a supracondylar fracture?

A

Get patient to make an ok sign with their thumb and index finger

25
Q

What is the common nerve injury with (peri)lunate dislocation/fracture?

A

Median nerve at the wrist

Causes loss of thumb aBduction

26
Q

What are the general features of a posterior cruciate ligament rupture?

A
  • Much larger ligament so needs strong force
  • Usually have associated injuries (hip injuries, dislocated etc)
  • Associated with blows to the leg when knee is flexed (ie falling onto flexed knee)
27
Q

What is the mortality of hip fractures in the elderly?

A

10% 1 month
25% at one year
50% 3 years

28
Q

How effective are the Ottawa knee rules?

A

100% sensitive, 40% specific
Reduced xray rates by approx 25-30% in adults and children without missing any fractures

29
Q

What is a segond fracture and what is its significance?

A

A small avulsion fracture of the proximal/lateral tibia
75% have associated ACL injuries and almost all have meniscus tears

30
Q

What are the risk factors for osteomyelitis?

A

Diabetes
Immunosuppression
IVDU
ATSI
Peripheral vascular disease
Sickle cell disease
Underlying metal wear
Iatrogenic (post procedure)

31
Q

What are the imaging modalites for osteomyelitis?

A

Xray
- low specificity/sensitivity

CT
- Rapid and easy, pre-op planning

MRI
- best sensitivity, gold standard, also high negative predictive value
- Can detect 3-5 days after infection has started
- Beware of non-MRI compatable metallic ortho implants

Nuclear med
- When MRI contraindicated and too much artefact on CT (ie metalwear)

32
Q

How dow you calculate an ankle brachial index (ABI)? What about an arterial pressure index (API)

A

ABI
- Lie the patient supine
- Take SBP in both arms
- Take SBP from the posterior tibial artery and the dorsalis pedis artery, use the higher number of the 2

API
- Place doppler over the artery
- Inflate cuff to 20mmHg beyond when the trace cuts off
- Release the cuff slowly, when the doppler signal comes back this is the SBP for that limb
- Do the same thing and compare with the affected limb

R) ABI/API = Highest pressure in R) foot / highest number from both arms

ie if R) brachial = 115, L) brachial = 110, R) dorsalis pedis = 80 and R) posterior tibial = 75
ABI = 80/115 = 0.7

Generally a ratio of <0.9 = arterial insufficiency

33
Q

What is the Garden classification system for fractures of the neck of femur?

A

Predicts the development of osteonecrosis, most commonly used but only applies to subcapital fractures

Garden 1- Undisplaced and incomplete impacted fractures
Garden 2- Undisplaced complete
- Garden 1 and 2 are stable and treated with internal fixation

Garden 3- Complete and partially displaced
Garden 4- Complete fracture and completely displaced
- Garden 3/4 unstable and treated with arthroplasty

34
Q

What are the different types based on position of femoral neck fractures? What is the important line that should be assessed on XR

A

Intracapsular
- Capital
- Subcapital (see Garden classes)
- Transcervical

Extracapsular
- Intertrochanteric
Subtrochanteric

35
Q

What is the Salter-Harris classification of physeal fractures?

A

Indicates worsening prognosis with higher grade injuries
- Type 1/2 often treated conservatively with a cast and reduction
- Type 3/4/5 often need surgery

Orthopaedics and Rheumatology (3 decks)

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